Epistaxis

A common sign, epistaxis (nosebleed) can be spontaneous or induced from the front or back of the nose. Most nosebleeds occur in the anterior-inferior nasal septum (Kiesselbach’s area), but they may also occur at the point where the inferior turbinates meet the nasopharynx. Usually unilateral, they seem bilateral when blood runs from the bleeding side behind the nasal septum and out the opposite side. Epistaxis ranges from mild oozing to severe — possibly life-threatening — blood loss.

A rich supply of fragile blood vessels makes the nose particularly vulnerable to bleeding. Air moving through the nose can dry and irritate the mucous membranes, forming crusts that bleed when they’re removed. Dry mucous membranes are also more susceptible to infections, which can produce epistaxis as well. Trauma is another common cause of epistaxis. Additional causes include septal deviations; hematologic, coagulation, renal, and GI disorders; and certain drugs and treatments.

Emergency Actions

If your patient has severe epistaxis, quickly take his vital signs. Be alert for tachypnea, hypotension, and other signs of hypovolemic shock. Insert a large-gauge I.V. line for rapid fluid and blood replacement, and attempt to control bleeding by pinching the nares closed. (However, if you suspect a nasal fracture, don’t pinch the nares. Instead, place gauze under the patient’s nose to absorb the blood.)

Have a hypovolemic patient lie down and turn his head to the side to prevent blood from draining down the back of his throat, which could cause aspiration or vomiting of swallowed blood. If the patient isn’t hypovolemic, have him sit upright and tilt his head forward. Constantly check airway patency. If the patient’s condition is unstable, begin cardiac monitoring and give supplemental oxygen by mask.

History

If your patient isn’t in distress, take a history. Does he have a history of recent trauma? How often has he had nosebleeds in the past? Have the nosebleeds been long or unusually severe? Has the patient recently had surgery in the sinus area? Ask about a history of hypertension, bleeding or liver disorders, and other recent illnesses. Ask if the patient bruises easily. Find out what drugs he uses, especially anti-inflammatories, such as aspirin, and anticoagulants such as warfarin.

Physical assessment

Begin the physical examination by inspecting the patient’s skin for other signs of bleeding, such as ecchymoses and petechiae, and noting any jaundice, pallor, or other abnormalities. When examining a trauma patient, look for associated injuries, such as eye trauma or facial fractures.

Medical causes

Aplastic anemia

Aplastic anemia develops insidiously, eventually producing nosebleeds as well as ecchymoses, retinal hemorrhages, menorrhagia, petechiae, bleeding from the mouth, and signs of GI bleeding. Fatigue, dyspnea, headache, tachycardia, and pallor may also occur.

Biliary obstruction

Biliary obstruction produces bleeding tendencies, including epistaxis. Typical features are colicky right-upper-quadrant pain after eating fatty food, nausea, vomiting, fever, flatulence and, possibly, jaundice.

Cirrhosis

With cirrhosis, epistaxis is a late sign that occurs along with other bleeding tendencies (bleeding gums, easy bruising, hematemesis, melena). Other typical late findings include ascites, abdominal pain, shallow respirations, hepatomegaly or splenomegaly, and fever. The patient may also exhibit muscle atrophy, enlarged superficial abdominal veins, severe pruritus, extremely dry skin, poor tissue turgor, abnormal pigmentation, spider angiomas, palmar erythema and, possibly, jaundice and central nervous system disturbances.

Coagulation disorders

Coagulation disorders, such as hemophilia and thrombocytopenic purpura, can cause epistaxis along with ecchymoses, petechiae, and bleeding from the gums, mouth, and I.V. puncture sites. Menorrhagia and signs of GI bleeding, such as melena and hematemesis, can also occur.

Glomerulonephritis (chronic)

Chronic glomerulonephritis produces nosebleeds as well as hypertension, proteinuria, hematuria, headache, edema, oliguria, hemoptysis, nausea, vomiting, pruritus, dyspnea, malaise, and fatigue.

Hepatitis

When hepatitis interferes with the clotting mechanism, epistaxis and abnormal bleeding tendencies can result. Associated signs and symptoms typically include jaundice, clay-colored stools, pruritus, hepatomegaly, abdominal pain, fever, fatigue, weakness, dark amber urine, anorexia, nausea, and vomiting.

Hypertension

Severe hypertension can produce extreme epistaxis, usually in the posterior nose, with pulsation above the middle turbinate. It may be accompanied by dizziness, a throbbing headache, anxiety, peripheral edema, nocturia, nausea, vomiting, drowsiness, and mental impairment.

Infectious mononucleosis

In patients with infectious mononucleosis, blood may ooze from the nose. Characteristic features include sore throat, cervical lymphadenopathy, and a fluctuating fever that peaks in the evening.

Influenza

When influenza affects the capillaries, a slow, oozing nosebleed results. Other signs and symptoms of influenza include dry cough, chills, fever, malaise, myalgia, sore throat, hoarseness or loss of voice, conjunctivitis, facial flushing, headache, rhinitis, and rhinorrhea.

Leukemia

With acute leukemia, sudden epistaxis is accompanied by a high fever and other types of abnormal bleeding, such as bleeding gums, ecchymoses, petechiae, easy bruising, and prolonged menses. These may follow less-noticeable signs and symptoms, such as weakness, lassitude, pallor, chills, recurrent infections, and low-grade fever. Acute leukemia may also cause dyspnea, fatigue, malaise, tachycardia, palpitations, a systolic ejection murmur, and abdominal or bone pain.

With chronic leukemia, epistaxis is a late sign that may be accompanied by other types of abnormal bleeding, extreme fatigue, weight loss, hepatosplenomegaly, bone tenderness, edema, macular or nodular skin lesions, pallor, weakness, dyspnea, tachycardia, palpitations, and headache.

Maxillofacial injury

With a maxillofacial injury, a pumping arterial bleed usually causes severe epistaxis. Associated signs and symptoms include facial pain, numbness, swelling, asymmetry, open-bite malocclusion or inability to open the mouth, diplopia, conjunctival hemorrhage, lip edema, and buccal, mucosal, and soft-palatal ecchymoses.

Nasal fracture

Unilateral or bilateral epistaxis occurs with nasal swelling, periorbital ecchymoses and edema, pain, nasal deformity, and crepitation of the nasal bones. Skin lacerations and abrasions may be present over the fracture.

Polycythemia vera

A common sign of polycythemia vera, spontaneous epistaxis may be accompanied by bleeding gums; ecchymoses; ruddy cyanosis of the face, nose, ears, and lips; and congestion of the conjunctiva, retina, and oral mucous membranes. Other signs and symptoms vary according to the affected body system but may include headache, dizziness, tinnitus, vision disturbances, hypertension, chest pain, intermittent claudication, early satiety and fullness, marked splenomegaly, epigastric pain, pruritus, and dyspnea.

Renal failure

Chronic renal failure is more likely than acute renal failure to cause epistaxis and a tendency to bruise easily. More common signs and symptoms are oliguria or anuria, weight loss, anorexia, abdominal pain, diarrhea, nausea, vomiting, tissue wasting, dry mucous membranes, uremic breath, Kussmaul’s respirations, deteriorating mental status, and tachycardia.

Skin changes include pruritus, pallor, yellow-bronze pigmentation, purpura, excoriation, uremic frost, and brown arcs under the nail margins. Neurologic signs and symptoms may include muscle twitches, fasciculations, asterixis, paresthesia, and footdrop. Cardiovascular effects include hypertension, arrhythmias, signs of heart failure, signs of pericarditis, and peripheral edema.

Sarcoidosis

Oozing epistaxis may occur in sarcoidosis, along with a nonproductive cough, substernal pain, malaise, and weight loss. Related findings include tachycardia, arrhythmias, parotid enlargement, cervical lymphadenopathy, skin lesions, hepatosplenomegaly, and arthritis in the ankles, knees, and wrists.

CULTURAL CUE:Sarcoidosis occurs predominantly among blacks in the United States. In addition, this condition affects twice as many women as men.

Sinusitis (acute)

With acute sinusitis, a bloody or blood-tinged nasal discharge may become purulent and copious after 24 to 48 hours. Associated signs and symptoms include nasal congestion, pain, tenderness, malaise, headache, low-grade fever, and red, edematous nasal mucosa.

Skull fracture

Depending on the type of fracture, epistaxis can be direct (when blood flows directly down the nares) or indirect (when blood drains through the eustachian tube and into the nose). Abrasions, contusions, lacerations, or avulsions are common. A severe skull fracture may cause severe headache, decreased level of consciousness, hemiparesis, dizziness, seizures, projectile vomiting, and decreased pulse and respiratory rates.

A basilar fracture may also cause bleeding from the pharynx, ears, and conjunctiva as well as raccoon eyes and Battle’s sign. Cerebrospinal fluid or even brain tissue may leak from the nose or ears. A sphenoid fracture may also cause blindness, whereas a temporal fracture may also cause unilateral deafness or facial paralysis.

Systemic lupus erythematosus

Usually affecting women younger than age 50, systemic lupus erythematosus (SLE) causes oozing epistaxis. More characteristic signs and symptoms include butterfly rash, lymphadenopathy, joint pain and stiffness, anorexia, nausea, vomiting, myalgia, and weight loss.

Other causes

Chemical irritants

Some chemicals — including phosphorus, sulfuric acid, ammonia, printer’s ink, and chromates — irritate the nasal mucosa, producing epistaxis.

Drugs

Anticoagulants, such as warfarin, and anti-inflammatory drugs, such as aspirin, can cause epistaxis. Cocaine use, especially if frequent, can also cause epistaxis.

Vigorous nose blowing

Vigorous nose blowing may rupture superficial blood vessels and cause epistaxis, especially in elderly people and young people.

Special considerations

Until the bleeding is completely under control, continue to monitor the patient for signs of hypovolemic shock, such as tachycardia and clammy skin. If external pressure doesn’t control the bleeding, insert cotton that has been impregnated with a vasoconstrictor and local anesthetic into the patient’s nose.

If bleeding persists, expect to insert anterior or posterior nasal packing. (See Controlling epistaxis with nasal packing, page 260.) Administer humidified oxygen by face mask to a patient with posterior packing.

A complete blood count may be ordered to evaluate blood loss and detect anemia. Clotting studies, such as prothrombin time and activated partial thromboplastin time, may be required to test coagulation time. Prepare the patient for X-rays if he has had recent trauma.

Pediatric pointers

Children are more likely to experience anterior nosebleeds, usually the result of nose picking or allergic rhinitis. Biliary atresia, cystic fibrosis, hereditary afibrinogenemia, and nasal trauma due to a foreign body can also cause epistaxis. Rubeola may cause an oozing nosebleed along with the characteristic maculopapular rash.

Suspect a coagulation disorder if you see excess umbilical cord bleeding at birth or profuse bleeding during circumcision.

Geriatric pointers

Elderly patients are more likely to have posterior nosebleeds.

Patient counseling

Advise the patient about proper pinching pressure techniques. For prevention, tell him to apply liberal amounts of petroleum jelly to his nostrils to prevent drying, cracking, and picking. Use of a humidifier at night and trimming fingernails are also recommended.

Pictures

Book Source Details

• Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.

Other Book Chapters Related to Nosebleeds

Read excerpts from these other book chapters related to Nosebleeds:

Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.

More About Causes of Nosebleeds

• Back to symptom: Nosebleeds: Introduction (review 260 causes)
• Next Book Extract About Nosebleeds: Hemoptysis (Signs & Symptoms: A 2-in-1 Reference for Nurses)
• All Book Extracts: All Online Book Extracts for Nosebleeds

More About This Book: Title: Signs & Symptoms: A 2-in-1 Reference for Nurses Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-318-1

 » Next page: Hemoptysis (Signs & Symptoms: A 2-in-1 Reference for Nurses)

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